Free Form 4977 (Rev. 02-2002) - Federal

Form

4977

Department of the Treasury- Internal Revenue Service

Tax period ended

(Rev. February 2002) Name

Schedule of Tax Liability
Employer Identification Number Telephone number (optional)

Number, street, and room or suite no.

City or town, state, and ZIP code

This form supports adjustments to: Form 1042 Form 940

Section I.
Line No. Period ending Tax liability for period (including any taxes assumed on Form(s) 1000)

Form 1042, Withholding Tax
Line No. Period ending Tax liability for period (including any taxes assumed on Form(s) 1000) Line No. Period ending Tax liability for period (including any taxes assumed on Form(s) 1000)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 April Mar. total March Feb. total Feb. Jan. total Jan.

7 15 22 31

21 22 23 24 25 May total May

7 15 22 31

41 42 43 44 45 Sept. total Sept.

7 15 22 30

7 15 22 28

26 27 28 29 30 June total June

7 15 22 30

46 47 48 49 50 Oct. total Oct.

7 15 22 31

7 15 22 31

31 32 33 34 35 July total July

7 15 22 31 1 7 15 August 22 31

51 52 53 54 55 56 57 58 59 60 Dec. total Dec Nov. total Nov.

7 15 22 31

7 15 22 30

36 37 38 39

7 15 22 31

Apr. total Aug. total 40 61 Total liability for year (add monthly total lines from above)

61

Section II.
Quarter First Second Third Fourth Total

Form 940, Unemployment Tax
Liability for Quarter (Do not include state liability)

Signature

Under penalties of perjury, I declare that I have examined the above liability schedule, and to the best of my knowledge and belief, it is true, correct, and complete. Date Title

Form 4977 (Rev. 02-2002)

Catalog Number 42142L